Evaluation of the Effect of a Concurrent Chronic Total Occlusion on Long-Term Mortality and Left Ventricular Function in Patients After Primary Percutaneous Coronary Intervention
Bimmer E.P.M. Claessen, MD,
René J. van der Schaaf, MD,
Niels J. Verouden, MD,
Nienke K. Stegenga, MSc,
Annemarie E. Engstrom, MD,
Krischan D. Sjauw, MD,
Wouter J. Kikkert, MD,
Marije M. Vis, MD,
Jan Baan, Jr, MD, PhD,
Karel T. Koch, MD, PhD,
Robbert J. de Winter, MD, PhD,
Jan G.P. Tijssen, PhD,
Jan J. Piek, MD, PhD,
José P.S. Henriques, MD, PhD*
Department of Cardiology, Academic Medical Center–University of Amsterdam, Amsterdam, the Netherlands
* Reprint requests and correspondence: Dr. José P. S. Henriques, Department of Cardiology, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands (Email: j.p.henriques{at}amc.uva.nl).
Objectives: The aim of this study was to evaluate the effect of a concurrent chronic total occlusion (CTO) in patients with ST-segment elevation myocardial infarction (STEMI) on long-term mortality and left ventricular ejection fraction (LVEF).
Background: The impact of a CTO in a non–infarct-related artery (IRA) on prognosis after STEMI is unknown.
Methods: Between 1997 and 2005, we admitted 3,277 STEMI patients treated with primary percutaneous coronary intervention. Patients were categorized as single-vessel disease (SVD), multivessel disease (MVD) without CTO, and MVD with a CTO in a non-IRA. We performed a "landmark survival analysis" to 5 years follow-up with a landmark set at 30 days. Additionally, we analyzed the evolution of LVEF within 1 year.
Results: Of the patients, 2,115 (65%) had SVD, 742 patients (23%) had MVD without CTO, and 420 patients (13%) had a concurrent CTO. Presence of a CTO was a strong and independent predictor for 30-day mortality (hazard ratio [HR]: 3.6, 95% confidence interval [CI]: 2.6 to 4.7, p < 0.01), whereas MVD without CTO was a weak predictor (HR: 1.6, 95% CI: 1.2 to 2.2, p = 0.01). In 30-day survivors, CTO remained a strong predictor (HR: 1.9, 95% CI: 1.4 to 2.8, p < 0.01), and MVD lost its independent prognostic value (HR: 1.1, 95% CI: 0.8 to 1.5, p = 0.45). Furthermore, CTO was associated with LVEF  40% immediately after STEMI (odds ratio: 1.9, 95% CI: 1.3 to 2.8, p < 0.01) and a further decrease in LVEF within the first year (odds ratio: 3.5, 95% CI: 1.6 to 7.8, p < 0.01).
Conclusions: The presence of a CTO and not MVD alone is associated with long-term mortality even when early deaths are excluded from analysis. The presence of a CTO is associated with reduced LVEF and further deterioration of LVEF.
Key Words: chronic total occlusion • left ventricular function • mortality • myocardial infarction • prognosis
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Abbreviations and Acronyms
| | CI = confidence interval | | CTO = chronic total occlusion | | HR = hazard ratio | | IQR = interquartile range | | IRA = infarct-related artery | | LVEF = left ventricular ejection fraction | | MVD = multivessel disease | | OR = odds ratio | | PCI = percutaneous coronary intervention | | STEMI = ST-segment elevation myocardial infarction | | SVD = single-vessel disease |
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